197607606-1-24-2025-31-AS-LDLC-DD8BEA-20250124000023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607606
Report Date: 01/23/2025
Date Signed: 01/24/2025 12:01:04 AM

Document Has Been Signed on 01/24/2025 12:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	NIKKEI SENIOR GARDENS		FACILITY NUMBER:	197607606
ADMINISTRATOR/ DIRECTOR:	DESIREE KITAGAWA		FACILITY TYPE:	740
ADDRESS:	9221 ARLETA AVE		TELEPHONE:	(818) 899-1000
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY: 106	TOTAL ENROLLED CHILDREN: 0	CENSUS: 79	DATE:	01/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Ericka Rivas, Business Office Director		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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On 1/23/2025, Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced annual inspection. LPA met with Business Office Director, Ericka Rivas disclosed the reason of the visit.

There are currently 79 residents who reside at this facility. This facility has a hospice waiver for 15 residents. At approximately 11:30am, LPA toured the facility with Ericka Rivas and the maintenance director, Alfonso Marron. Facility is designated by two resident areas which is the assisted living area and a memory care unit area.

In the assisted living unit area, LPA inspected five (5) resident bedrooms, the kitchen, the dining area, an activity room, the theater room, the solarium also known as the tv room, laundry rooms and a gym. In the memory care unit LPA inspected three (3) resident rooms, the mini kitchen area and the activity room.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient supply of perishable and non-perishable food and were properly stored. Knives, cleaning agents, and other potentially hazardous items were locked and inaccessible. Kitchen has industrial refrigerators and a large food pantry. All the foods in the refrigerator and pantry are labeled and dated. LPA observed the walk-in freezer maintaining the required temperature of 0 degrees Fahrenheit

Resident bedrooms and bathrooms: Bathrooms and bedrooms were clean and in good repair. LPA observed clean beds, lamp, night stand, chair and a desk with a desk chair. Hot water temperature was tested and ranged from 107.5 degrees F - 110.7 degrees F. Signal system checked and observed operable during visit.

Continued to LIC809C

Naira Margaryan	TELEPHONE: (818) 596-4368
Leizl De La Cerra	TELEPHONE: (818) 454-0632
	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NIKKEI SENIOR GARDENS	FACILITY NUMBER: 197607606
	VISIT DATE: 01/23/2025

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Common Areas: The dining area, the activity room, the theater room, the solarium also known as the tv room, and the gym were observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed.

Laundry Rooms: LPA observed two (2) laundry rooms in the facility. Laundry rooms were observed to be clean and inaccessible to residents. Cleaning supplies, and other toxins, were securely stored and inaccessible to residents.

Outdoor: There are various sitting areas surrounding the facility. LPA observed these areas to have more than adequate shade, with sufficient tables and chairs for the residents. All outdoor furniture observed to be in good condition. There are no bodies of water in the facility.

In addition to the physical plant inspection, residents records, staff files and resident medications were reviewed between 1:00pm to 4:00pm. LPA reviewed five (5) staff files, all appeared to be complete and updated. LPAs reviewed ten (10) resident records all appeared to be complete and updated.

Medications: Residents medication are centrally stored in the medication room which is inaccessible to the residents. Three (3) centrally stored resident medications were reviewed with Samantha Orduna, Health and Wellness Director. First Aid kit was also observed and it is complete.

Administrative: LPAs collected a copy of Administrator's certificate of Shin Ito. Certificate of Liability Insurance effective until 12/01/25, LIC500 and LIC9020. Facility emergency disaster plan was reviewed. Fire extinguishers are located all throughout the facility and were last serviced 08/02/2024. Fire Drill was last conducted on 12/20/2024. Fire alarms, smoke detectors and carbon monoxide detectors observed through out the facility and were recently tested on 7/01/2024.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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